FOR OFFICE USE ONLY. IACUC PROTOCOL NUMBER: IACUC Approval has been granted for the project described in this document

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1 ADMINISTRATIVE COVER SHEET FOR AN APPLICATION TO USE LIVE VERTEBRATE ANIMALS IN FIELD RESEARCH Arkansas Tech University Institutional Animal Care and Use Committee (IACUC) FOR OFFICE USE ONLY IACUC PROTOCOL NUMBER: IACUC Approval has been granted for the project described in this document Original Approval Date: Approval Period: From To Please submit this form electronically as a single.pdf document to the IACUC at IACUC@atu.edu. (Paper submissions will not be accepted). CHECK ONE: 1. TITLE OF PROJECT: New Application 3 Year Renewal - Be sure to include any modifications to procedures when completing the new application. Please provide the previously assigned IACUC protocol number: 2. PRINCIPAL INVESTIGATOR (PI) INFORMATION: (If not ATU Faculty, include an ATU Faculty sponsor, see Question #4) Please indicate how you prefer to be contacted: Fax PI Name: Work Address: Department: Work Phone: FAX #: Emergency phone (after hours) #: Cell #: Address: 3. CO- INVESTIGATOR (CI) INFORMATION: (If not an ATU Faculty, include an ATU Faculty sponsor, see Question #4) Please indicate how you prefer to be contacted: Fax PI Name: Work Address: Department: Work Phone: FAX #: Emergency phone (after hours) #: Cell #: Address: Page 1

2 4. CONTACT PERSON FOR PAPERWORK ISSUES (if other than PI): N/A Please indicate how person prefers to be contacted: Fax Name: Work Address: Department: Work Phone: FAX #: Address: 5. ATU FACULTY SPONSOR: (required if PI is not ATU faculty): N/A Please indicate how person prefers to be contacted: Fax Name: Work Address: Department: Work Phone: FAX #: Address: 6. QUALIFICATIONS AND TRAINING OF PERSONNEL: Please list all personnel** associated with Arkansas Tech University (e.g. formal volunteer, student, faculty, staff) who will be working with or handling live vertebrate animals associated with this protocol: **For each individual, including the PI who is listed above, include a brief descripion of qualifications to be involved in the research. 7. FUNDING (Check all that apply): Intramural Funding: (e.g. Departmental funds, personal funds, various donors/gifts, etc.) Protocols funded by the Department or any non-peer reviewed source require Department Chair signature (Section 9 in this application). Extramural Funding: Please provide the following information for extramural funding that has been or is expected to be funded (e.g. fundable score, JIT, IACUC congruency approval required prior to proposal submission, etc). AGENCY/ SPONSOR PI OF AWARD AGENCY AWARD NUMBER IRES PROPOSAL NUMBER TITLE Page 2

3 APPLICATION TO USE LIVE VETEBRATE ANIMALS IN FIELD RESEARCH Arkansas Tech University Institutional Animal Care and Use Committee OFFICE USE ONLY Protocol Number: Approval Period: From To PI NAME: DEPT.: WORK PHONE: TYPE OF PROJECT (please check one): Research Teaching/training Collection/Banking Behavioral Manipulation All sections of the application must be completed within the form field provided. If a specific section of this application does not apply to your project, please indicate that it is not applicable (NA). If attachments are necessary to provide a response to a specific section, the attachment must be clearly referenced under the appropriate section and the section number noted on the attachment. SECTION 1: RELEVANCE OF RESEARCH Provide a brief synopsis of the project and of its overall objectives and intended benefits to humans, animals and/or the advancement of scientific knowledge. This section should be understandable to a general reader at an 8 th grade level. Page 3

4 SECTION 2: ANIMALS REQUESTED 1) Please list what taxonomic grouping (species if applicable) of vertebrate animals or species will be involved in the study: 2) Please indicate, if applicable, the number of animals listed on the Permit: ( If nothing is listed on the permit, only then please continue on to question #3) 3) Given time constraints in the field, logistics, and other issues (weather, etc.), what is the maximum number of target species that you could conceivably use in the study? (Please note that at annual report the actual number of animals collected and species name must be provided to the IACUC.) 4) Which of the following USDA pain categories applies to the procedures done on animals in your study? B animals collected and bred/held as part of the project C procedures will cause no (or minimal) pain or distress (e.g. injections, blood sampling, tattooing) D procedures involve pain or distress but anesthetics, analgesic or tranquilizing drugs are used E procedures involve pain or distress and no anesthetic, analgesic or tranquilizing drugs can be used (e.g. leg hold trap) If any category E procedures will be performed, provide the approximate number and group name: If more than one category applies please describe/explain: 5) Please provide photocopies of all current permits that authorize the proposed field activity. If current permits are not available, previously issued permits or a copy of the application for the current permit may be submitted temporarily in order to demonstrate concept. Up to date permits must be filed with the IACUC upon receipt in order to be compliant with regulations on animal use numbers. I have attached complete/full copies of all current permits I have attached previously issued permits or a copy of the application for a current permit and will file up to date permits with the IACUC when received Permits do not apply: If permits do not apply to your project, please explain/describe. If permits are not required, if possible, please provide documentation to that effect such as a copy of the regulatory statute or a letter from the appropriate law enforcement agency. Please note additional information may be required for studies that do not require permits. 6) I confirm that at annual review of this project, a copy of my permit annual report will be provided if applicable or a list of each species used in the study and the exact number of individuals will be submitted to the IACUC. 7) I confirm I will abide by state and federal regulations and any local requirements. This includes, but is not limited to, the USDA, FDA, USFWS and the DOT. Page 4

5 SECTION 3: JUSTIFICATION FOR SPECIAL CIRCUMSTANCES N/A If your project involves (1) USDA Category E Procedures, or (2) Death as an Endpoint (i.e. lethality is used as the experimental endpoint rather than euthanasia), or endpoints involving severe morbidity or impairment, strong written scientific justification with particular attention to significance, necessity, and potential benefits of the research is required below: SECTION 4: JUSTIFICATION FOR THE USE OF ANIMALS a) Provide the rationale for the use of live vertebrate animals in this project: b) Explain the scientific rationale for the choice of each species or other taxonomic grouping: c) Explain why the estimated number of animals is necessary (e.g. sample must include ranges of age/stage, sexes, geographic variation, etc.) Page 5

6 SECTION 5: PROCEDURES/ACTIVITIES TO BE DONE ON LIVE VERTEBRATE ANIMALS Which of the following activities will occur to live animals in the field? If checked, answer follow-up questions in Section 6: Capture, other than via trap Trapping Tagging or marking Collection via noxious event (includes gunshot, poison, snap trap, etc.) Euthanasia, other than via lethal event Other SECTION 6: DESCRIPTION OF PROCEDURES/ACTIVITIES Capture, other than via trap: Please describe capture methods (i.e. hand or hand-held noose, net, tongs): Will live animals be brought into Arkansas Tech University? No Yes If YES, please answer the following questions: a) describe what will be done to the animals while at ATU: b) where will the animals be held? c) how long will live animals remain at ATU? d) if animals are euthanized, please outline the process including euthanasia method, dose and route of administration: e) identify transport methods including information regarding maintaining appropriate environment, and food and water sources if applicable: Will animals be housed at Arkansas Tech University longer than 12 hours? No Yes If YES, please provide the following information: a) Who in Veterinary Clinical Services has been contacted to discuss housing and care of the animals? b) Where will the animals be housed? a. Farm Facility: Building: Room number: b. Laboratory Housing: Building: Room number: Will venomous or otherwise dangerous live vertebrate animals be brought into Arkansas Tech University? No Yes If YES, please address the following issues: a) identify the poisonous species: b) identify the venom or poison if known: c) is venom or poison part of the research? d) indicate where emergency anti-venom sources will be maintained: e) describe emergency transportation of anti-venom: Please note that additional information may be required by the IACUC prior to approval. Page 6

7 Non-lethal Trapping: Please indicate the type of trap: Sticky boards Sherman Havahart Mist net Other; please describe: What is the maximum time an animal could spend in a trap before discovery? Please explain/justify. How will trapping non-target species be avoided? Indicate the fate of any trapped non-target species: What will be the fate of any animals wounded in the traps? Tagging or marking: Please indicate the type of tag including the make and model as well as manufacturer (including coded wire tags, bands, ear tags, pit tags, Floy fish tags, sterile beads, etc.): If non-tag marking is used, please describe the method. Fin clip Toe clip Belly scale clip Tattoo Stains/dyes Shell etching Other; please describe: If marking involves cutting or piercing skin, please describe any antiseptic precautions to be taken and/or pain management: Page 7

8 Euthanasia via noxious event (includes gunshot, rotenone, snap trap, etc.): Please describe the noxious event in detail and provide indications of relevant permits and safety precautions: Describe how killing non-target species will be avoided: Describe what will happen to any animals wounded, but not killed. Euthanasia, other than via noxious event: What euthanasia technique will be used? Please indicate the method including dosages: **Please be reminded that many drugs, controlled substances, and some other products are highly regulated materials, and may require permits or special licenses for lawful transportation across state lines or into other countries. Investigators are responsible for ensuring the lawful transport of all of their research materials to avoid legal action up to and including capital punishment.** Note that euthanasia techniques must comply with the AVMA Guidelines on Euthanasia and/or the Arkansas Tech University Policies on euthanasia. If the required technique does not, please provide scientific rationale for deviation. Other: Please describe/explain. Page 8

9 SECTION 7: OTHER HAZARDS How will you protect your safety during animal collection? Will your work involve other hazardous materials, objects, equipment or activities? If so, please list. A Request to Use Hazardous Agents form must also be submitted for all hazardous agents. SECTION 9: DEPARTMENT APPROVAL Required only if the animals will be used in teaching or training or if the animal research will be supported by departmental or non peer-reviewed funding. The Department Chair must read the protocol and sign below indicating department approval before IACUC approval may be granted. Note: If the Department Chair is also an investigator on the protocol, this approval must be obtained from the next highest level of administrative authority not involved in the project. I have read the Application to Use Animals, and find this research to be appropriate in design and that the investigator (or faculty sponsor) is competent to perform (or supervise) this study. My signature below denotes departmental approval of this study as submitted. Typed Name Signature Date Signed Department Chair Department Chair Page 9

10 INVESTIGATOR S ASSURANCE For the Arkansas Tech University Institutional Animal Care and Use Committee (IACUC) By virtue of submitting this application, I, the Primary Investigator, ensure the following: 1. I agree to abide by PHS policy, USDA Regulations, the National Research Council Guide for the Care and Use of Laboratory Animals, all federal regulations, and policies of Arkansas Tech University governing the use of animals in research, teaching and testing. 2. If live vertebrate animals will be returned to Arkansas Tech University I will permit emergency veterinary intervention, even if it could compromise my experiments, for animals showing evidence of pain or illness not addressed specifically in the approved protocol, in addition to appropriate veterinary care as prescribed for individual species. I understand that it is my responsibility to provide current and updated emergency contact information if veterinary intervention will compromise my experiments. 3. I declare that all personnel having direct live animal contact on this project, including myself, have been or will be trained in humane and scientifically acceptable procedures for animal handling, procedural techniques, administration of anesthesia, analgesia and euthanasia to be used in this project, and all are aware of the hazards involving the use of live animals and tissues. Personnel will be allowed adequate time to obtain training necessary for this project. 4. I ensure that all personnel involved in this project will be informed of the procedures outlined in the protocol. 5. I certify that the information provided within this application is accurate to the best of my knowledge. I also understand that should I use the project described in this application as a basis for a proposal for funding (either intramural or extramural), it is my responsibility to ensure that the description of animal use in such funding proposal is identical in principle to that contained in this application. 6. I certify that all Arkansas Tech University personnel in this project will attend the mandatory IACUC Orientation. 7. I am aware that the use of hazardous agents in animals may only be initiated after approval from IACUC. CONSIDERATION OF UNNECESSARY DUPLICATION: 8. I certify that I have consulted the following sources and, to the best of my knowledge, the experiments described in this protocol do not unnecessarily duplicate previous experiments or unnecessarily use animals (check all applicable sources): National Agricultural Library Library of Congress Medline Other (Please specify): Zoological record/biosis Page 10

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